How long have you been a customer with us?
Less than 1 year 1-3 years 3-5 years 5+ years
Which product/service do you use most frequently?
Product A Product B Service A Service B Multiple products/services equally
What do you value most in our products/services?
Quality Price Customer service Innovation Convenience
How likely are you to recommend us to others?
Highly likely Likely Unlikely Highly unlikely
Do you participate in our loyalty program?
Yes, regularly Yes, occasionally No, but interested No, not interested
All set, how can we reach you?
Name
Email
Phone
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